EFTA00313927.pdf

pat\ 11:U Langone MEDICAL CENTER Heis.pm Wyss Department of Plastic Surgery 305 East 33rd Street New York, NY 1001 Patient Name: 5 e — Fficel GPs-reiNI Date of Bette --cz Cl - 19 SS Consent for Diagnostic & Treatment Photographs I understand that photographs may be taken vi connection with consultation. diagnostic testing. surgical procedu physicians of NYU Plastic Surgery, Drs. Daniel Cern:M res and treatments by the I. Roberto Fares, Mesas Hazen, Jamie Levine, Eduardo Rodrigu Sharma. baud Stoltenberg, VEshal Thanlk, and Barry ez, Pierre Saadeh, Shoe Zede or the Nine PractitionersAmanda Young, Kimberly Monon NEcole Sweeney 1 understand that failure to consent to these a, Whitney Sala and photographs wawa NYU Plastic Surgery the right to decline my treatment erAS -re u--I Print Patient/Guardian Name Relationship to Patient Patent/Guardian Signature Date Email / Call Consent , Join our online newsletter to receive anhouncements, news and learn about mein offers at NYU PIBSIAC Surgery and The institute of Reconstructhe Plastic Surgery. To 'on, please provide us with your 'Please Print/ Name'. Final Address. Prolettre iw pr/racy us nponant to Nn e5 and the eltPS. We str o keep your pencrol rdormshon cOarilJeltoi wei rear Mare your utinnapart. If you wish to be called with our earltIng offers Please 41sest number to call you. Telephone Number By checking this boa. you agree we can lea a message at the numbbi provided about our offers Best time to till: Q11-10am /0 12pm - 2pm Q 4 To unsubscribe horn out emailIng or call1(a, please Send an email to NYUPIastkSu'tteryponimc.org with the subject line. / words linsubscribe me on the / N..,.,.. Date' .Signature EFTA00313927